Question

Diagnostic Results:

Complete Blood Count (CBC):	Current:	High/Low/WNL?
Sodium	134
Potassium	3.8
Chloride	100
CO2	27
BUN	17
Creatinine	1.8
Glucose	103

What lab results are RELEVANT and clinically significant?

RELEVANT Lab(s):	Clinical Significance:

Does your initial nursing priority or plan of care need to be modified in any way after obtaining these lab results?

1. What is the primary problem that your patient is most likely presenting with?

2. What is the underlying cause/pathophysiology of this concern?

3. What body system(s) will you most thoroughly assess based on the primary/priority concern?

4. What is the most likely complication to anticipate?

5. What nursing assessment(s) will you need to initiate to identify this complication if it develops?

List the nursing interventions you will initiate based on this priority. Provide the rationale and the expected outcome for each. Is the intervention dependent or independent?

Nursing Intervention:	Rationale:	Expected Outcome:	Independent or dependent intervention:

Prepare the ISBAR-R call to the physician.

Introduction:

Situation:

Background:

Assessment:

Recommendation:

Read back:

The physician agrees with your concerns and decides to order open urinary catheter irrigation using 100mL normal saline as needed. Write the order on the sheet below.

Date/Time	Physician Order Sheet

       

       

       

Describe the difference between open and closed urinary catheter irrigation?

What is a 3-way catheter and why is it used?

Your shift is complete. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of the patient. What is the difference between a physician call ISBAR-R and a shift hand-off ISBAR-R?

In what situation might you differ these reports?

Answer 1

1. What lab results are RELEVANT and clinically significant?

Creatinine if high (Normal levels of creatinine in the blood are approximately 0.6 to 1.2 milligrams (mg) per deciliter (dL) in adult males and 0.5 to 1.1 milligrams per deciliter in adult females). This indicates a kidney dysfunction (or failure)

2. Does your initial nursing priority or plan of care need to be modified in any way after obtaining these lab results?

Patinet's intake and output chart has be maintained. If it is not already included in the nursing priority or plan of care, that also has to be added.

3. What is the primary problem that your patient is most likely presenting with?

Most likely, the patient will be suffering from kidney dysfunction\kidney failure

4. What is the underlying cause/pathophysiology of this concern?

If the kidney is not working properly, the creatinine level will go high since the filtering (of waste materials from food, medications, and toxic substances) process is not happening properly. As a result, Creatine, Urea and Nitrogen may go high.

5. What body system(s) will you most thoroughly assess based on the primary/priority concern?

Urinanry system since the Creatinine level is high. It indicates the dysfunction of kidney. That may develop oliguria ( low output of urine). Also, will thoroughly assess for any breathing difficulty, chest pain, swelling etc. A patient may develop these problems if the kidney is not functioning properly. If the kidney is not filtering properly, that may end up in oliguria and patient may have excess fluid in the body , which sometimes leads to swelling. Also, this may affect Pulmonary circulation ( blood between the heart and the lungs) and the patient may develop chect pain and breathing difficulty